Provider Demographics
NPI:1497233886
Name:BOUCHARD, KYLEE ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:KYLEE
Middle Name:ANN
Last Name:BOUCHARD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:268 STILLWATER AVE
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-3945
Mailing Address - Country:US
Mailing Address - Phone:207-973-6100
Mailing Address - Fax:
Practice Address - Street 1:268 STILLWATER AVE
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3945
Practice Address - Country:US
Practice Address - Phone:207-973-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-30
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC173531041C0700X
MELC220491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical